National Guideline for Primary Health care workers

Osteoporosis
Prevention and Management

Directorate of Public Health

Non communicable Disease Department

IRAQ 2021
National Guideline for Primary
Health care workers
 Osteoporosis
Prevention and Management

Directorate of Public Health

Non communicable Disease Department
IRAQ 2021
 Contributors to the National Guideline for Osteoporosis
Prevention and Management Version 2
❖ Dr.Tariq Jassim. M DRMR specialist of rheumatology. AL Karkh General
Hospital MOH.
❖ Dr. Khudair Z Mayouf Albedri. Professor Doctor Consultant Rheumatologist
Consultant Internist.
❖ Dr.Abbas Toma consultant Rheumatology assistant Prof.AL-Mustansiriyia
Collage of Medicine.
❖ Dr.Muna Atalla Khaleefa Ali, Director of Noncommunicable prevention &
control Department, Directorate of public health, MOH.
❖ Dr.Bushra Ibrahim Abdul-Lattif AL-Nassar, Director of Elderly Health Section,
NCD prevention &control Department, Directorate of public health, MOH.
❖ Dr.Batool A Hasan, Director of musculoskeletal disease prevention, NCD
prevention &control Department, Directorate of public health, MOH.
❖ Dr. Sally A Witwit. Director of Elderly health Unit, NCD prevention &control
Department, Directorate of public health, MOH.
❖ Dr.Wasan A Rasheed. Division Director of nutritional counseling/Nutrition
Research Institute.
❖ Pharmacist Alaa C Abdulzahra. Integrated NCD Care Unit, NCD prevention
&control Department, Directorate of public health, MOH.
❖ Dr. Ahmed A Hasan, General Surgeon, Therapeutic Department, Technical
Affairs Directorate.

Contributors to the National Guideline for Osteoporosis

Prevention and Management Version 1
❖ Dr.Tariq Jassim. M DRMR specialist of rheumatology. AL Karkh General
Hospital MOH.
❖ Dr. Muna Atallah K.Ali. FICMS/CM. Director of Noncommunicable Diseases
Section/ General Directorate of Public Health. MoH .
❖ Dr. Ola Shakir Fadhil. Family Physician Specialist. Director of MCH\RH
section –MOH, Member of Consultant Committee of Family Medicine, Iraqi
Family Physcians Society( IFPS) Vice President)
❖ Dr.Shaimaa M. J. Ibrahim. Gyn. & Obst. / RH Specialist. PHC Department /
MCH & RH Unit. MoH
❖ Dr.Lujain K. Al-Dabbagh, FICMS/CM. MCH & RH Section- General
Directorate of Public Health. MoH.Dr.Bushra Ibrahim Abd Al Lattif Al Nassar.
MSc. In Community Medicine Manager of Elderly Health Program NCD
Section .
❖ Dr.Bushra Ibrahim Al-Nassar M.Sc. Com.Med. Elderly Care Unit Manager.
NCD Section. PHC Dep. General Directorate of Public Health. MoH.
❖ Dr.Nada Abdul Wahab Mousa Ph.D. Com.Med. Integrated NCD Care Unit
Manager. NCD Section. PHC Dep. General Directorate of Public Health. MoH.
❖ Dr. Ali Abdalkader Ali CAB-Com. Med. Integrated NCD Care Section, Medical
Officer of Chronic Respiratory Unit. General Directorate of Public Health.
MOH .
CONTENTS
ABBREVIATIONS…………………………………………………………………….……....3

OSTEOPOROSIS DEFINITION……………………………….…………………….……...4

OSTEOPOROTIC FRACTURES……………………………………………………….…..4

PATHOPHYSIOLOGY………………………………………………………………….……4

TYPES OF OSTEOPOROSIS……………………………………………………….….…..5

RISK FACTORS OF OSTEOPOROSIS…………………………………………….…...…6

OSTEOPOROSIS FRACTURE RISK PREDICTION……………………………………..7

CLINICAL ASSESSMENT OF OSTEOPOROSIS……………………………….………..7

DIAGNOSIS OF OSTEOPOROSIS AND RELATED FRACTURE………………………8

MANAGEMENT OF OSTEOPROSIS………………………………………………………10

NON PHARMACOLOGIC THYERAPY…………………………………………………….10

1- Adequate intake of calcium and vitamin D…..……………………………………10

2- Active lifestyle including regular exercise…………………………………………13
3- Avoiding unhealthy habits…………………………………………………………..13

PHARMACOLOGIC THYRAPY…………………………………………………………….14

FOLLOW-UP AND MONITORING EFFECTIVENESS OF TREATMENT……………..14

PREVENTING OF OSTEOPOROSIS……………………………………………………..15

FALL PREVENTION……………………….……………………………………………..…..16

REFERENCES…………………………………………………………………………………

ANNEXES…………………………………………………………………………………..….19
ABBREVIATIONS

BMD Bone Mineral Density

DEXA Dual-Energy X-Ray Absorptiometry

DV Dietary Value

DXA Dual-Energy X ray Absorptiometry

ET/HT Estrogen / Hormones therapy

FDA Food and Drug Association

FRAX Fracture Risk Assessment

FAO Food and Agriculture Organization

GNRH Gonadotropin Releasing Hormone

NOF National Osteoporosis Foundation

SD Standard Deviations

SERMs Selective Estrogen Receptor Modulators

WHI Woman's Health Initiative

WHO World Health Organizations

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OSTEOPOROSIS DEFINITION: -
Osteoporosis, which literally means porous bone, is a disease in which the density and
quality of bone are reduced. As bones become more porous and fragile, the risk of
fracture is greatly increased. The loss of bone occurs silently and progressively. Often
there are no symptoms until the first fracture occurs. Osteoporosis affects an enormous
number of people, of both sexes and all races.
It’s estimated over 200 million women have osteoporosis

OSTEOPOROTIC FRACTURES: -
Around the world, 1 in 3 women and 1 in 5 men are at risk of an osteoporotic fracture.
In fact, an osteoporotic fracture is estimated to occur every 3 seconds. The most
common fractures associated with osteoporosis occur at the hip, spine and wrist. The
likelihood of these fractures occurring, particularly at the hip and spine, increases with
age in both women and men.
Fractures may be followed by full recovery or by chronic pain, disability and death.
The economic costs of osteoporotic fractures include expenses for surgery and
hospitalization, rehabilitation, long-term care, medications, and loss of productivity.
Osteoporosis is preventable and treatable, but due to the absence of warning signs prior
to a fracture, many people are not diagnosed in time to receive effective therapy during
the early phase of the disease.

PATHOPHYSIOLOGY: -
The process of bone remodeling that maintains a healthy skeleton may be considered
a preventive maintenance program (continually removing older bone and replacing it
with new bone). Bone loss occurs when this balance is altered, resulting in greater bone
removal than replacement, bones weaken (osteopenia) and over time can become
brittle and prone to fracture (osteoporosis)

Bone mass in older adults equals the peak bone mass achieved by the age 18-25 years
minus the amount of bone subsequently lost. Peak bone mass is determined largely by
genetic factors, with contributions from nutrition, endocrine status, physical activity and
health during growth.

The pathophysiologic basis of osteoporosis is multifactorial and includes the genetic

determination of peak bone mass, subtle alteration in bone remodeling due to changes
in systemic and local hormones (estrogen, parathyroid hormone, and to a lesser extent
testosterone), and environmental influence (Fig1).

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The pathophysiologic basis of osteoporosis is multifactorial and includes the genetic
determination of peak bone mass, subtle alteration in bone remodeling due to changes
in systemic and local hormones (estrogen, parathyroid hormone , and to a lesser
extent testosterone), and environmental influence (Fig1).

Normal Bone Osteoporotic Bone

Fig (1) Micrographic of Normal vs. Osteoporotic Bone
Source: NOF Clinician Guide to Prevention and Treatment of Osteoporosis2010.

Osteoporosis fractures result from a combination of decreased bone strength and an

increased incidence of falls with aging.

TYPES OF OSTEOPOROSIS: -
1- Primary osteoporosis
➢ Juvenile osteoporosis this is a condition in which osteoporosis develops in a
previously healthy child or teenager and often no clear reason can be found.

➢ Idiopathic osteoporosis can be further subdivided into postmenopausal (type I)

due to estrogen deficiency and age-associated or senile (type II) osteoporosis
due to an aging skeleton and calcium deficiency.
2- Secondary osteoporosis
Medical conditions resulting in secondary osteoporosis may include: -
➢ Serious kidney failure
➢ Cushing's disease (a tumor of the pituitary gland, responsible for secreting some
of the body's hormones)
➢ Liver impairment
➢ Anorexia nervosa and bulimia
➢ Rheumatoid arthritis
➢ Malabsorption syndromes such as celiac disease
➢ Multiple sclerosis
➢ Chronic obstructive pulmonary disease

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 ➢ Scurvy

Secondary osteoporosis can also have hormonal causes: -

➢ Hyperparathyroidism: increased activity of the parathyroid glands
➢ Hyperthyroidism: an excessive secretion of the thyroid glands
➢ Diabetes
➢ Hypercortisolism: a result of systemic illness or long-term use of oral
corticosteroid
➢ Other links to secondary osteoporosis
➢ Thalassemia: a hereditary form of anemia
➢ Multiple myeloma: multiple tumors within the bone and bone marrow
➢ Leukemia: a serious disease that is characterized by unrestrained growth of
white blood cells in the tissues
➢ Metastatic bone diseases

Other types of osteoporosis occur during or soon after pregnancy in otherwise

apparently healthy women (Osteoporosis associated with pregnancy)

RISK FACTORS OF OSTEOPOROSIS: -

1- Fixed risk factors )factors can’t change(
➢ Age
➢ Female gender
➢ Family history
➢ Previous fracture
➢ Ethnicity
➢ Menopause or hysterectomy
➢ Hysterectomy, if accompanied by removal of the ovaries,
➢ Primary or secondary hypogonadism in men
➢ Secondary Risk Factors include: -
1- Disorders that affect the skeleton
• Asthma
• Nutritional/gastrointestinal problems (e.g. Crohn’s or celiac disease)
• Rheumatoid arthritis
• Haematological disorders/malignancy
• Some inherited disorders
• Hypogonadal states (e.g. Turner syndrome/Kleinfelter syndrome, amenorrhea)
• Endocrine disorders (e.g. Cushing’s syndrome, hyperparathyroidism, diabetes)
• Immobility
2- Medical treatments affecting bone health
• Long term glucocorticoid therapy
• Certain immunosuppressant (calmodulin/calcineurine phosphatase inhibitors)
• Thyroid hormone treatment (L-Thyroxine)
• Certain steroid hormones (medroxyprogesterone acetate, leutenising hormone
releasing hormone agonists)
• Aromatase inhibitors
• Certain antipsychotics

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 • Certain anticonvulsants
• Certain antiepileptic drugs
• Lithium
• Methotrexate
• Antacids
• Proton pump inhibitors
2- modifiable risk factors )factors can change(
➢ Alcohol
➢ Smoking
➢ Low Body Mass Index
➢ Poor nutrition
➢ Vitamin D deficiency
➢ Eating disorders
➢ Estrogen deficiency
➢ Insufficient exercise
➢ Frequent falls

OSTEOPOROSIS FRACTURE RISK PREDICTION: -

The Fracture Risk Assessment (FRAX) tool has been developed by WHO to evaluate
fracture risk of patients. It is based on individual patient models that integrate the risks
associated with clinical risk factors as well as bone mineral density (BMD) at the
femoral neck. The algorithms give the 10-year probability of fracture. The output is a
10-year probability of hip fracture and the 10-year probability of a major osteoporotic
fracture (clinical spine, forearm, hip or shoulder fracture). (Annex1).

CLINICAL ASSESSMENT OF OSTEOPOROSIS: -

History: -
➢ Careful evaluation should include:
➢ Life style factors including exercise, dietary intake of calcium and caffeine,
smoking, alcohol consumption, level of sun exposure.
➢ Changes in height and weight.
➢ Previous fractures.
➢ Risk factors of osteoporosis.
➢ Bone pain. Usually osteoporosis is not painful until fracture occurs.
➢ Family history of metabolic bone disease other than osteoporosis like
hyperparathyroidism or osteomalacia.
Physical examination: -
➢ The following should be considered:
➢ Height measurement in comparison with standard height. The loss of 5 cm is
sensitive indicator to vertebral compression.
➢ Presence of kyphosis may indicate pulmonary compression.
➢ Signs of associated conditions.
➢ Observation of gait.

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DIAGNOSIS OF OSTEOPOROSIS AND RELATED FRACTURE: -
Traditional X-rays can’t measure bone density, but they can identify spine
fractures. Bone mineral density (BMD) has to be measured by more specialized
techniques. A number of different types of BMD tests are available, but the most
commonly used is DEXA (dual-energy X-ray absorptiometry)
DXA is a low radiation X-ray capable of detecting quite small percentages of bone loss.
It is used to measure spine and hip bone density, is the most common technique for
assessing the risk of osteoporosis and can also measure bone density of the whole
skeleton.

Peripheral devices include: -

- Quantitative ultrasound.
- Peripheral quantitative computed tomography.
- Peripheral DXA.
Objectives for BMD measurement: -
The main objectives for BMD measurement are:-
➢ To diagnose Osteopenia or osteoporosis.
➢ To predict fracture risk.
➢ To monitor the response of BMD to therapy.

Diagnostic criteria for osteoporosis: -

BMD criteria is used for the diagnosis of osteoporosis. Two types of scores are used to
quantify BMD.
T score: is the number of Standard Deviations SD the person’s BMD measurement
as compared to the “young normal adults” mean BMD of Caucasian women of the
same sex (table 2).

Z score: is the number of Standard Deviations SD the person’s BMD measurement

as compared to the “age-matched” expected mean BMD (table 3).
A change of 1 SD in either the T or Z score corresponds to a change of BMD of
approximately 10%.

The World Health Organization (WHO) provided criteria for the diagnosis of normal
bone mass, low bone mass in osteopenia and osteoporosis. These criteria are based on
comparisons to peak adult bone mass density (BMD) from population of Caucasian
postmenopausal women.

8
Table (1) World Health Organization (WHO) Criteria for diagnosis of
osteoporosis.

Classification T Score(SD below BMD)

Normal ≥ -1

Osteopenia Between -1 to -2.5

Osteoporosis ≤ -2.5

Severe osteoporosis ≤ -2.5 plus fracture

In premenopausal women, men less than 50 years of age and children, the WHO BMD
diagnostic classification should not be applied. Instead, ethnic or race adjusted age
matched Z scores should be used (table3).

Table (2) BMD classification based on Z score

Classification Z Score (SD below BMD)

Within expected range for age > -2

Below expected range for age ≤ -2.5

BMD measured by DXA is the strongest known predictor of hip and spinal fractures. For
each decline of approximately 1 standard deviation of BMD there is 1.3 to 3 fold
increase in the risk of fractures.
Although fracture risk at any site can be assessed accurately by DXA, BMD at the
femoral neck is a better predictor of hip fracture than BMD at the spine, radius, or
calcaneus.

Indications for Referral for BMD measurement: -

1- Women aged 65 and older
2- For post-menopausal women younger than age 65 a bone density test is indicated if they have a
risk factor for low bone mass such as:
➢ Low body weight
➢ Prior fracture

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 ➢ High risk medication use
➢ Disease or condition associated with bone loss
3- Women during the menopausal transition with clinical risk factors for fracture, such as low body
weight, prior fracture, or high-risk medication use
4- Men aged 70 and older
5- For men < 70 years of age a bone density test is indicated if they have a risk factor for low bone
mass such as:
➢ Low body weight
➢ Prior fracture
➢ High risk medication use
➢ Disease or condition associated with bone loss
6- Adults with a fragility fracture
7- Adults with a disease or condition associated withlow bone mass or bone loss
8- Adults taking medications associated with low bone mass or bone loss
9- Anyone being considered for pharmacologic therapy
10- Anyone being treated, to monitor treatment effect
11- Anyone not receiving therapy in whom evidence of bone loss would lead to treatment
12- Women discontinuing estrogen

MANAGEMENT OF OSTEOPOROSIS: -
The main goal of osteoporosis management is to prevent occurrence of the first
fracture or recurrence of fractures:
NONPHARMACOLOGIC THERAPY: -
Lifestyle modification Aspects for bone health include:
1-Adequate intake of calcium and vitamin D: -
- Calcium
is important for preventing osteoporosis and bone disease, the amount of calcium we
need to consume changes at different stages in our lives. Calcium requirements are
high in our teenage years with the rapid growth of the skeleton with age, the body’s
ability to absorb calcium declines, some examples of the approximate calcium content
in common foods are shown in (annex 2).

Recommended daily calcium intakes: -

Recommended daily calcium allowances for populations vary between countries. The
IOM 2010 (Institute of Medicine of the US National Academy of Sciences)
recommendations are as follows:

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 infancy to adolescence calcium (mg/day)

0-6 months *

6-12 months *

1-3 years 700

4-8 years 1000
9-13 years 1300
14-18 years 1300
Women calcium (mg/day)

19 - 50 years 1000

Post-menopause (51+ years) 1200

During pregnancy/lactation 14-18 years old 1300

During pregnancy/lactation 19-50 years old 1000

Men calcium (mg/day)

19-70 years 1000

70+ years 1200

* For infants, adequate intake is 200 mg/day for 0 to 6 months and 260 mg/day for 6 to 12 months of age.

-Vitamin D
is essential for the development and maintenance of bone, both for its role in assisting
calcium absorption from food in the intestine, and for ensuring the correct renewal and
mineralization of bone tissue.
Sources of vitamin D: -
➢ Vitamin D from sunlight exposure
Vitamin D is made in the skin when it is exposed to ultraviolet B rays; in children and
adults exposure of the hands, face and arms to the sun for 10 to 15 minutes per day
is usually sufficient for most individuals. However, how much vitamin D is produced
from sunlight depends on the time of day, where you live in the world and the color
of your skin.
➢ Vitamin D from food, and dietary supplements
Food sources are rather limited, and include oily fish such as salmon, sardines and
mackerel, eggs, liver, and in some countries fortified foods such as margarine, dairy
foods and cereals. Some examples of the approximate vitamin D levels in foods are
shown in (annex 3).
Recommended vitamin D intake: -

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Because the sun provides a source of vitamin D in varying amounts for different
individuals, dietary recommendations for vitamin D are approximate. Many countries
advise a dietary intake of 200 IU/day (5 µg/day) * for children and young adults, and
400-600 IU/day (10-15 µg/day) for older persons, to augment that derived via sun
exposure. The Institute of Medicine (IOM) dietary intake recommendations are shown
below.

Dietary Reference Intakes for Vitamin D

recommended dietary recommended dietary
age group
allowance (IU/day) allowance (µ/day)

Infants 0-6 months ** 10 µg/day

Infants 6-12 months ** 10 µg/day

1-70 years 600 *** 15 µg/day

>70 years 800 20 µg/day

Source: Institute of Medicine (IOM), USA with modification
*To convert from IU of vitamin D3 to µg of vitamin D3, multiply by 0.025
*For infants, Adequate Intake is 400 IU/day for 0-12 months of age
** IOF recommendations for adults aged 60 years and over are 800 to 1000 IU/day for falls and
fracture protection
There is as yet no common definition of ‘optimum’ vitamin D status, although there is
emerging evidence and expert opinion that the minimum blood level of 25-
hydroxyvitamin D that would be optimal for fracture prevention is 70-80 nmol/l1. To
achieve this, an average older man or woman would need a vitamin D intake of at least
800-1000 IU/day (20-25 µg/day), which is approximately double the intake
recommended in most countries.

For seniors (60 yrs. and older)- Given the indoor-lifestyle of most seniors, little
sunshine in winter months, and the various physiological factors related to ageing, it is
very common for seniors to have poor vitamin D status. IOF therefore recommends
that seniors aged 60 years and over take a supplement at a dose of 800 to 1000
IU/day. Vitamin D supplementation at these levels has been shown to reduce the risk of
falls and fractures by about 20%.

There are a number of foods, nutrients and vitamins, that help to prevent osteoporosis
and contribute to bone, muscle and joint health, including protein, fruits and vegetables,
and other vitamins and minerals. (annex 4)

Vitamin D deficiency: -
➢ In children, severe vitamin D deficiency results in inadequate mineralization of
the bone matrix, leading to growth retardation and bone deformities known as
rickets.

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 ➢ In adults, the same condition is known as osteomalacia. In industrialized
countries.
➢ Maintaining adequate vitamin D status during pregnancy is important, as there is
some evidence that mothers deficient in 25-hydroxyvitamin D in pregnancy give
birth to children with reduced bone mass, which could in turn be a risk factor for
osteoporosis later in life.
2-Active lifestyle including regular exercise: -
Exercise plays an important role in building and maintaining bone and muscle strength.
Lifelong physical activity at all ages is strongly recommended, both for osteoporosis
prevention and overall health, as benefits are lost when the person stops exercising.
(annex5)

Exercise is vital for bone and muscle health: -

➢ It builds strong bones in youth. It’s estimated a 10% increase of peak bone mass
in children can reduce the risk of an osteoporotic fracture during adult life by 50%.
➢ Exercise plays a key role in adults preventing bone loss and maintaining muscle
strength.
➢ It helps prevent weak bones and falls in the elderly. One-third of people over 65
have a fall each year and the risk of falling increases as age rises.
➢ People who have suffered fractures can benefit from special exercises and
training (under medical supervision) to improve muscle strength and muscle
function for greater mobility and improved quality of life.

Regular Weight-Bearing and Muscle-Strengthening Exercise: -

It is recommended to practice regular weight-bearing and muscle-strengthening
exercise to reduce the risk of falls and fractures:
➢ Weight-bearing exercise: in which bones and muscles work against gravity as
the feet and legs bear the body’s weight including walking, jogging, stair climbing
and tennis.
➢ Muscle-strengthening exercise: includes weight training and other resistive
exercises

3-Avoiding unhealthy habits: -

➢ Coffee
Coffee-based drinks are increasingly popular among adolescents. Studies in
adults have shown that drinking more than three cups of coffee daily may
interfere with calcium absorption and have a negative impact on bone health
➢ Soft drinks
It has been suggested that excessive consumption of carbonated soft drinks,
particularly cola, can damage bone health due to their high phosphate content.
While there is no scientific evidence to support this claim, soft drinks definitely do
not contribute to good bone health. They have no nutritional value, and young
people who drink more sodas have a correspondingly lower intake of milk or

13
 other calcium-rich drinks, contributing to the so-called “milk-displacement effect”.

➢ Body weight and bone health

A healthy body weight during childhood and adolescence is required for optimal
bone health. Having a body mass (BMI) at either end of the spectrum can pose a
threat into the development of the skeleton. Anorexia nervosa is especially
damaging to bone mass and strength in the young. Overweight children have low
bone mass for their weight and are more likely to suffer wrist fractures.
Pharmacologic Therapy: - (prescribe by specialist in secondary level)
Treatments have been shown to reduce the risk of hip fracture by up to 40%,
vertebral fractures by 30-70% and, with some medications, reduce the risk for
non-vertebral fractures by 15-20%.

Medically approved drug therapies for the treatment of osteoporosis and

prevention of fractures (annex6).

FOLLOW-UP AND MONITORING EFFECTIVENESS OF TREATMENT

It is important to follow-up with the patient:
➢ Encourage continued and appropriate compliance with their osteoporosis
therapies to reduce fracture risk.
➢ Review their risk factors and encourage appropriate calcium and vitamin D
intakes with exercise,
➢ Ensure Fall Prevention and other lifestyle measures.
➢ Serial central DXA BMD testing in accordance with medical necessity,
expected response and in consideration of local regulatory requirements.
➢ IOF recommends repeated BMD assessments every two years, but
recognizes that testing more frequently may be warranted in certain clinical
situations.

PREVENTING OF OSTEOPOROSIS
osteoporosis may be prevented by adopting a bone healthy lifestyle at all stages
of life.

In fact, osteoporosis prevention begins in childhood, when a bone-healthy diet and

plenty of exercise helps children achieve their highest possible ‘peak bone mass’. This
is important because the more bone mass you have when you reach adulthood, the less
likely you are to have weak and breakable bones at older age.

For women early prevention is especially important. The diagram below shows how
bone loss occurs rapidly after menopause, at around the age of 50, when the protective

14
effect of estrogen is lost.

Osteoporosis prevention in adults

➢ Ensure a healthy diet which includes enough calcium and protein, two key
nutrients for bone health.
➢ Get enough vitamin D - made in the skin after exposure to sunlight, the
average young adult needs about 15 minutes of daily sun exposure. You can
boost your vitamin D intake through some foods like oily fish, eggs,
mushrooms, and fortified dairy foods or juices.
➢ Maintain a healthy body weight - being too thin (BMI under 19) is damaging to
your bone health.
➢ Keep active Take regular weight-bearing and muscle strengthening exercise.
➢ Avoiding smoking and drinking
➢ Be aware of your osteoporosis risk factors, and get an early diagnosis,
and treatment if needed.
Osteoporosis prevention in seniors (60 years and older)

Older adults are at highest risk of osteoporosis, with nearly 75% of hip, spine and wrist
fractures occurring in people aged 65 years old or over. The prevention advice listed
below applies to all adults, but at older age one should pay special attention to the
following:

➢ Ensuring enough calcium, protein, vitamin D and other nutrients: With age,
your ability to absorb vitamins and minerals may be reduced. In fact, older
adults often suffer from malnutrition as they may not be eating enough and
getting enough protein and vitamins in their diets. A calcium and vitamin D
supplement should be considered when dairy consumption is low, and little
time is spent outdoors.
➢ Practicing exercise activities that improve balance, posture, coordination, and
muscle strength.
➢ cautious should be taken to prevent falls inside and out home.(annex 7)
➢ assessment for the presence of risk factors for osteoporosis (table 1).

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FALL PREVENTION
One-third of people over 65 have a fall each year globally and the risk of falling
increases as age rises . Falls can seriously impact independence, resulting in ongoing
disability, changes in lifestyle, reduced activity and as a result social isolation and death.

1- Risk factors for falls

The majority of osteoporosis- related fractures result from falls. Therefore, it is important
to assess the risk of falls (table2)

Table (2) Risk Factors for Falls

Aging
Anxiety and agitation
Arrhythmias
Dehydration
Depression
Female gender
Impaired transfer and mobility
Vitamin D insufficiency
Malnutrition
Medications causing oversedation (narcotic analgesics,
anticonvulsants, psychotropics)
Orthostatic hypotension
Poor vision and use of bifocals
Previous fall
Reduced problem solving or mental acuity and diminished cognitive
skills
Urgent urinary incontinence
Kyphosis
Poor balance
Reduced proprioception
Weak muscles
Lack of indoor and outdoor safety measures for prevention of falls
Fear of Falling
Source: NOF Clinician’s Guide 2014 with modification

The impact of falls is compounded in people with osteoporosis, often resulting in

multiple appendicular and proximal fractures. Hip fracture carries high mortality rate due
to associated serious complication.
Once one fracture has occurred, the chances of having another fracture
increases.

2- Steps to prevent falls

Strategies to reduce falls include, but are not limited to:

16
 ➢ Maintain adequate vitamin D levels and physical activity, as described
earlier.
➢ Checking and correction of vision and hearing.
➢ Evaluating any neurological problems.
➢ Reviewing prescription medications for side effects that may affect
balance
➢ Wearing undergarments with hip pad protectors for patients who have
significant risk factors for falling or for patients who have previously
fractured a hip.
➢ Provision of safety requirements for indoor and outdoor environments
(Annex 7).
3- exercise for fall prevention
Falls and related fractures are a major health problem for older individuals
and for society. Changes in sensory and musculoskeletal structure and
function among older adults puts them at increased risk of falls and injuries.
Many intrinsic and external risk factors for falls have been identified.
Exercise can modify the intrinsic fall risk factors and thus prevent falls in
older adults (annex8).

Exercises not suitable for people with osteoporosis

Several exercises are not suitable for people with osteoporosis as they can exert strong
force on relatively weak bone. Dynamic abdominal exercises like sit-ups and excessive
trunk flexion can cause vertebral crush fractures. Twisting movements such as a golf
swing can also cause fractures. Exercises that involve abrupt or explosive loading, or
high-impact loading, are also contraindicated. Daily activities such as bending to pick up
objects can cause vertebral fracture and should be avoided.

17
REFERENCES:

- IOF. Clinical Practice Guideline for Osteoporosis Screening and Treatment 2020.
- Klipple John H. (2008). Primer on the Rheumatic Diseases . 13th Edition. Springer.
P565-598.
-National Osteoporosis Foundation. 2014. Clinician’s Guide to Prevention and
Treatment of Osteoporosis. Washington DC. Bone Source

-The Society of Obstetricians and Gynaecologysts of Canada. Menopause and

Osteoporosis. Journal of Obstetrics and Gynaecology Candada . 2009; 31 (1)
Supplement 1: 534-540
- WHO. (2007). Assessment of Osteoporosis at The Primary Health Care Level. WHO..

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ANNEXES
Annex (1) Fracture Risk Assessment Tool (FRAX)Calculation Tool

http://www.shef.ac.uk/FRAX/tool.jsp

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 Annex (2) calcium content in food
Milk
FOOD SERVING SIZE CALCIUM (MG)
Milk, semi-skimmed 200 ml 240
Milk, skimmed 200 ml 244
Milk, whole 200 ml 236
Milkshake 300 ml 360
Sheep milk 200 ml 380
Coco milk 200 ml 54
yoghurt
FOOD SERVING SIZE CALCIUM (MG)
Yoghurt, flavored 150 g 197
Yoghurt, with fruit pieces 150 g 169
Yoghurt, natural 150 g 207
Cheese
FOOD SERVING SIZE CALCIUM (MG)
Hard cheese 30 g 240
e.g. Cheddar, Parmesan, Emmental, Gruyere
Fresh cheese 200 g 138
e.g. cottage cheese, ricotta, mascarpone
Soft cheese 60 g 240
e.g. Camembert, Brie
Feta 60 g 270
Mozzarella 60 g 242
Cream cheese portion, 30 g 180

Cream, desserts
FOOD SERVING SIZE CALCIUM (MG)
Cream, double, whipped 30 ml 21
Cream full 30 ml 21
Custard made with milk, vanilla 120 g 111
Ice cream, vanilla 100 g 124
Pudding, vanilla 120 g 120
Pancake 80 g 62
Cheese Cake 200 g 130
Waffle 80 g 47
Meat, fish and eggs

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 FOOD SERVING SIZE CALCIUM (MG)
Egg 50 g 27
Red meat 120 g 7
Chicken 120 g 17
Fish e.g. Cod, Trout, Herring, Whitebait 120 g 20
Tuna, canned 120 g 34
Sardines in oil, canned 60 g 240
Shrimp 150 g 45
Beans & lentils
FOOD SERVING SIZE CALCIUM (MG)
Lentils 80 g raw/ 200 g cooked 40
Chick peas 80 g raw/ 200 g cooked 99
White beans 80 g raw/ 200 g cooked 132
Red beans 80 g raw/ 200 g cooked 93
Green/French beans 90 g cooked 50
Starchy foods
FOOD SERVING SIZE CALCIUM (MG)
Pasta (cooked) 180 g 26
Rice, white (boiled) 180 g 4
Potatoes (boiled) 240 g 14
White bread slice, 40 g 6
Whole meal bread slice, 40 g 12
Muesli (cereals) 50 g 21
Naan 60 g 48
Fruits
FOOD SERVING SIZE CALCIUM (MG)
Orange 150 g 60
Apple 120 g 6
Banana 150 g 12
Apricot 3 pieces, 120 g 19
Currant (dried gooseberry) 120 g 72
Figs, dried 60 g 96
Raisins (dried grapes) 40 g 31
Vegetables
FOOD SERVING SIZE CALCIUM (MG)
Lettuce 50 g 19
Kale, Collard greens 50 g (raw) 32

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 FOOD SERVING SIZE CALCIUM (MG)
Bok Choy/Pak Choi 50 g (raw) 20
Broccoli 120 g (raw) 112
Gombo/Okra 120 g (raw) 77
Cress 120 g (raw) 188
Rhubarb 120 g (raw) 103
Carrots 120 g (raw) 36
Tomatoes 120 g (raw) 11
Nuts & seeds
FOOD SERVING SIZE CALCIUM (MG)
Almonds 30 g 75
Walnuts 30 g 28
Hazlenuts 30 g 56
Brazil Nuts 30 g 28
Sesame seeds 15 g 22
Tahini Paste 30 g 42
Processed foods
FOOD SERVING SIZE CALCIUM (MG)
Quiche (cheese, eggs) 200 g 212
Omelette with cheese 120 g 235
Pasta with cheese 330 g 445
Pizza 300 g 378
Lasagna 300 g 228
Cheeseburger 200 g 183

Note: - 1 cup = 250 ml

1 Table spoon = 15ml
1 Teaspoon = 5ml
1 piece of triangular cheese = 15ml

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 Annex (3) VIT D level in food
Approximate vitamin D levels in foods

MCG PER IU PER RNI* (FOR AGES

FOOD
SERVING SERVING 51-65 YEARS)

Cod liver oil**, 1 tbsp 23.1 924 231

Salmon, grilled, 100g 7.1 284 71
Mackerel, grilled, 100g 8.8 352 88
Tuna, canned in brine, 100g 3.6 144 36
Sardines, canned in brine, 100g 4.6 184 46
Margarine, fortified, 20g 1.6 62 16
Bran Flakes***, average serving, 30g 1.3 52 13
Egg, hen, average size, 50g 0.9 36 9
Liver, lamb, fried, 100g 0.9 36 9

* The RNI (recommended nutrient intake) is defined by the FAO/WHO as “the daily
intake which meets the nutrient requirements of almost all (97.5%) apparently healthy
individuals in an age- and sex-specific population group”. Daily intake corresponds to
the average over a period of time.
** Fish liver oils, such as cod and halibut liver oil, contain small amounts of vitamin A,
which can be toxic if consumed in excess.
***Bran Flakes are given as an example of a vitamin D-fortified breakfast cereal.

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 Annex (4) Nutrition and bone

Protein
Adequate dietary protein is essential for optimal bone mass gain during childhood and
adolescence. It’s also responsible for preserving bone mass with ageing. Lack of protein
robs the muscles of strength, which heightens the risk of falls, and contributes to poor
recovery in patients who have had a fracture.

Lean red meat, poultry and fish, as well as eggs and dairy foods, are excellent
sources of animal protein. Vegetable sources of protein include legumes (e.g.
lentils, kidney beans), soya products (e.g. tofu), grains, nuts and seeds.

Fruits and Vegetables

Fruits and vegetables contain an array of vitamins, minerals, antioxidants and alkaline
salts - some or all of which can have a beneficial effect on bone. Studies have shown
higher fruit and vegetable consumption is associated with beneficial effects on bone
density in elderly men and women.

Other vitamins and minerals

B Vitamins and Homocysteine

Some studies suggest high blood levels of the amino acid homocysteine may be linked
to lower bone density and higher risk of hip fracture in the elderly. Vitamins B6 and B12,
as well as folic acid, play a role in changing homocysteine into other amino acids for use
by the body, so it is possible that they might play a protective role in osteoporosis.
Research is ongoing as to whether supplementation with these B vitamins might reduce
fracture risk.

Magnesium

Magnesium plays an important role in forming bone mineral. Magnesium deficiency is

rare in well-nourished populations. The elderly are sometimes risk of mild magnesium
deficiency, as magnesium absorption decreases with age. Particularly good sources
of magnesium include green vegetables, legumes, nuts, seeds, unrefined grains
and fish.

Vitamin A
The role of vitamin A in osteoporosis is controversial. Vitamin A is present as a
compound called retinol in foods of animal origin, such as liver and other offal,
fish liver oils, dairy foods and egg yolk. Some plant foods contain a precursor of

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vitamin A, for example in green leafy vegetables, and red and yellow coloured
fruits and vegetables. Consumption of vitamin A in amounts well above the
recommended daily intake may have adverse effects on bone.

Such high levels of vitamin A intake are probably only achieved through over-use of
supplements, and intakes from food sources are not likely to pose a problem. Further
research is needed into the role of vitamin A in bone health, although many countries at
present caution against taking a fish liver oil supplement and a multivitamin supplement
concurrently.

Vitamin K
Vitamin K is required for the correct mineralization of bone. Some evidence suggests
low vitamin K levels lead to low bone density and increased risk of fracture in the
elderly. Vitamin K sources include leafy green vegetables such as lettuce, spinach
and cabbage, liver and some fermented cheeses and soya bean products.

Zinc
This mineral is required for bone tissue renewal and mineralization. Severe deficiency
is usually associated with calorie and protein malnutrition, and contributes to impaired
bone growth in children. Milder degrees of zinc deficiency have been reported in the
elderly and could potentially contribute to poor bone status. Sources of zinc include
lean red meat, poultry, whole grain cereals, pulses and legumes.

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 Annex (5) exercise recommendations for prevention and
treatment of osteoporosis

Recommended level of physical activity for health

5–17 years old
For children and young people of this age group physical activity includes play, games,
sports, transportation, recreation, physical education or planned exercise, in the context
of family, school, and community activities.
In order to improve cardiorespiratory and muscular fitness, bone health, cardiovascular
and metabolic health biomarkers and reduced symptoms of anxiety and depression, the
following are recommended:
1. Children and young people aged 5–17 years old should accumulate at least 60
minutes of moderate to vigorous-intensity physical activity daily.
2. Physical activity of amounts greater than 60 minutes daily will provide additional
health benefits.
3. Most of daily physical activity should be aerobic. Vigorous-intensity activities should
be incorporated, including those that strengthen muscle and bone, at least 3 times per
week

18–64 years old

For adults of this age group, physical activity includes recreational or leisure-time
physical activity, transportation (e.g. walking or cycling), occupational (i.e. work),
household chores, play, games, sports or planned exercise, in the context of daily,
family, and community activities.
In order to improve cardiorespiratory and muscular fitness, bone health and reduce the
risk of NCDs and depression the following are recommended:
1. Adults aged 18–64 years should do at least 150 minutes of moderate-intensity
aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-
intensity aerobic physical activity throughout the week, or an equivalent combination of
moderate- and vigorous-intensity activity.
2. Aerobic activity should be performed in bouts of at least 10 minutes duration.
3. For additional health benefits, adults should increase their moderate-intensity aerobic
physical activity to 300 minutes per week, or engage in 150 minutes of vigorous-
intensity aerobic physical activity per week, or an equivalent combination of moderate-
and vigorous-intensity activity.
4. Muscle-strengthening activities should be done involving major muscle groups on 2
or more days a week.

65 years old and above

For adults of this age group, physical activity includes recreational or leisure-time
physical activity, transportation (e.g. walking or cycling), occupational (if the person is
still engaged in work), household chores, play, games, sports or planned exercise, in
the context of daily, family, and community activities.
In order to improve cardiorespiratory and muscular fitness, bone and functional health,

26
and reduce the risk of NCDs, depression and cognitive decline, the following are
recommended:
1. Adults aged 65 years and above should do at least 150 minutes of moderate-intensity
aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-
intensity aerobic physical activity throughout the week, or an equivalent combination of
moderate- and vigorous-intensity activity.
2. Aerobic activity should be performed in bouts of at least 10 minutes duration.
3. For additional health benefits, adults aged 65 years and above should increase their
moderate intensity aerobic physical activity to 300 minutes per week, or engage in 150
minutes of vigorous intensity aerobic physical activity per week, or an equivalent
combination of moderate- and vigorous intensity activity.
4. Adults of this age group with poor mobility should perform physical activity to
enhance balance and prevent falls on 3 or more days per week.
5. Muscle-strengthening activities should be done involving major muscle groups, on 2
or more days a week.
6. When adults of this age group cannot do the recommended amounts of physical
activity due to health conditions, they should be as physically active as their abilities and
conditions allow.

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 Annex (6) Pharmacological Therapy of Osteoporosis
A number of pharmacological agents are approved by FDA for the treatment as well as
of osteoporosis. Not all of these drugs are available in every country. All increase bone
mineral density and reduce the risk of fractures:
➢ Bisphosphonates: (alendronate, risedronate, ibandronate,
zoledronic acid)
analogues of inorganic pyrophosphate that inhibit bone resorption, Adsorbed onto
hydroxyapatite crystals in bones , slowing both their rate of growth and dissolution , and
therefore reducing the rate of bone turnover.

Alendronate (10 mg daily tablet, 70 mg weekly tablet or liquid formulation, and 70

mg weekly tablet with 2,800 IU or 5,600 IU of vitamin D3).
Risedronate sodium (5 mg daily tablet; 35 mg weekly tablet; 35 mg weekly tablet
packaged with 6 tablets of 500 mg calcium carbonate; 75 mg tablets on two
consecutive days every month; and 150 mg monthly tablet)
➢ Calcitonin:
It increases deposition of calcium and phosphate in the bone and lowers levels in
the blood.
It is delivered as a single daily intranasal spray that provides 200 IU of the drug.
Subcutaneous administration by injection also is available.

➢ Estrogen/Hormone Therapy (ET/HT)

It is approved for the prevention of osteoporosis, relief of vasomotor symptoms and
vulvovaginal atrophy associated with menopause. Women who have not had a
hysterectomy require HT which contains progestin to protect the uterine lining.
The Woman’s Health Initiative (WHI) found that five years of HT reduced the risk of
clinical vertebral fractures and hip fractures by 34 percent Because of the risks of
cardiovascular diseases and breast cancer, ET/HT should be used in the lowest
effective doses for the shortest duration to meet treatment goals. It is no longer
regarded as a front-line option for the prevention or the treatment of osteoporosis in
postmenopausal women. Their use is limited to:
1. Women who have both osteoporosis and menopausal symptoms which is severe
enough to affect life quality.
2. Premature menopause (if women reach menopause at age <40). Until they are 50
years old, if this is not associated with any increasing health risk

➢ Estrogen Agonist/Antagonist (formerly known as SERMs)

Raloxifene: it is indicated for the reduction in risk of invasive breast cancer in
postmenopausal women with osteoporosis. It does not reduce the risk of coronary heart
disease. Similar to estrogen, Raloxifene may increase the risk of deep vein thrombosis.
It also increases hot flashes and make it worse (which is the main symptom of
menopause worsen).

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 ➢ Parathyroid hormone
Teriparatide is anabolic agent administered by daily subcutaneous injection. Because
of its effect on incidence of osteosarcoma in animal experimental studies, it is
recommended that its use for a maximum of two years and that those at risk of
malignancy should not use it.
➢ Denosumab
it is human monocolonal antibody that inhibits osteoclast formation , function , and
survival , theraby decreasing bone resorption

SUPPLEMENTATION AND LIFESTYLE

In addition to drug therapy, calcium and vitamin D supplements can be prescribed to
ensure maximum effectiveness of your medication. You should be aware that attention
to lifestyle factors (including risk factors , nutrition and exercise) must go hand in hand
with any drug treatment prescribed.

PRACTICAL SUPPORT
Practical and emotional support is important for anyone on osteoporosis treatment. This
can be provided by health professionals, osteoporosis patient support groups, family
and friends. Such support will help you manage your osteoporosis, and lessen any
feelings of isolation and depression (experienced by many patients with severe
osteoporosis).

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 Annex (7) Fall Prevention Safety Requirements

The following advices should be given:

Outdoor Safety Tips

Try the following tips to help prevent falls when you are outside:

➢ Wear low-heeled shoes with rubber soles for more solid footing (traction), and
wear warm boots in winter.
➢ Use hand rails as you go up and down steps and on escalators.
➢ If sidewalks look slippery, walk in the grass for more solid footing.
➢ In winter, carry a small bag of rock salt in your pocket or car. You can then
sprinkle the salt on sidewalks or streets that are slippery.
➢ Look carefully at floor surfaces in public buildings. Floors made of highly
polished marble or tile can be very slippery. When these surfaces are wet, they
may become dangerous. When floors have plastic or carpet runners in place,
stay on them whenever possible.
➢ Keep your porch, deck, walkways and driveway free of leaves, snow, trash or
clutter. Also keep them in good repair. Cover porch steps with a gritty, weather-
proof paint and install handrails on both sides.
➢ Turn on the light outside your front door before leaving your home in the early
evening so that you have outdoor light when you return after dark.
➢ Use a shoulder bag, fanny pack or a backpack purse to leave your hands free.
➢ Use a walker or cane as needed.
➢ Find out about community services that can provide help, such as 24-hour
pharmacies and grocery stores that take orders by phone or internet and
deliver, especially in poor weather.
➢ Stop at curbs and check the height before stepping up or down. Be careful at
curbs that have been cut away to allow access for bikes or wheelchairs. The
incline may lead to a fall.
➢ Consider wearing hip protectors or hip pads for added protection should you
fall.
Indoor Safety Tips: Fall-Proofing Home

Try the following tips to help prevent falls when you are inside your home:

Around the House

➢ Place items you use most often within easy reach. This keeps you from having
to do a lot of bending and stooping.
➢ Use assistive devices to help avoid strain or injury. For example, use a long-
handled grasping device to pick up items without bending or reaching. Use a
pushcart to move heavy or hot items from the stove or countertop to the table.
➢ If you must use a stepstool, use a sturdy one with a handrail and wide steps.

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 ➢ Also consider having a wireless telephone or cell phone to take from room to
room so you can call for help if you fall.
Floors

Remove all loose wires, cords and throw rugs.

Keep floors free of clutter.

Be sure all carpets and area rugs have skid-proof backing or are tacked to the floor.

Do not use slippery wax on bare floors.

Keep furniture in its usual place.

Bathrooms

Install grab bars on the bathroom walls beside the tub, shower and toilet.

Use a non-skid rubber mat in the shower or tub.

If you are unsteady on your feet, you may want to use a plastic chair with a
back and non-skid legs in the shower or tub with and use

a handheld showerhead to bathe.

Kitchen

Use non-skid mats or rugs on the floor near the stove and sink.

Clean up spills as soon as they happen (in the kitchen and anywhere in the home).

Bedroom

Place light switches within reach of your bed and a night light •
between the bedroom and bathroom.

Get up slowly from sitting or lying down since this may cause
dizziness.

Keep a flashlight with fresh batteries beside your bed.

Keep your medications and walking aid near

Stair

Keep stairwells well lit, with light switches at the top and the bottom. •

31
Install sturdy handrails on both sides.
Mark the top and bottom steps with bright tape. Make sure carpeting is secure.

In addition to indoor and outdoor hazards, certain lifestyle behaviors can make a
person more likely to fall. Here are some lifestyle tips to help you:

➢ Stay alert and focused when in public places.

➢ Remember to wear appropriate shoes both indoors and out.
➢ If you are in a hurry, slow down. Accidents are more likely to happen when
you rush.
➢ Get your vision checked
➢ .Have an annual medication review conducted by a healthcare provider or
pharmacist.
➢ Avoid drinking alcohol. Alcohol slows reflexes and may cause confusion,
dizziness or disorientation. Too much alcohol can also cause bone loss.
➢ Avoid medications that increase falls risk.
➢ Exercise and eat healthy food at every age. A healthy diet includes having a
well-balanced diet that contains the recommended amounts of calcium and
vitamin D.

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 Annex (8) Exercise for prevention fall

Exercise 1: Single Limb Stance

It’s best to start off with a simple balance exercise for
seniors. Here’s how you do this one: stand behind a
steady, solid chair (not one with wheels), and hold on
to the back of it. Lift up your right foot and balance on
your left foot. Hold that position for as long as you
can, then switch feet.
The goal should be to stand on one foot without
holding onto the chair and hold that pose for up to a
minute.

Exercise 2: Back Leg Raises

This strength training exercise for seniors makes your
bottom and your lower back stronger.
Stand behind a chair. Slowly lift your right leg straight
back – don’t bend your knees or point your toes. Hold
that position for one second, then gently bring your
leg back down. Repeat this ten to 15 times per leg.

Exercise 3: Side Leg Raise

You’ll need a chair for this exercise to improve
balance.
Stand behind the chair with your feet slightly apart.
Slowly lift your right leg to the side. Keep your back
straight, your toe facing forward, and stare straight
ahead. Lower your right leg slowly. Repeat this
exercise ten to 15 times per leg.

Exercise 4: Toe Lifts

This strength training exercise for seniors also
improves balance. You’ll need a chair or a counter.
Stand straight and put your arms in front of you. Raise
yourself up on your toes as high as you can go, then
gently lower yourself. Don’t lean too far forward on the
chair or counter. Lift and lower yourself 20 times.

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Exercise 5: Wall Pushups
As long as you’ve got a wall, you can do this strength
training exercise for seniors.
Stand an arm’s length in front of a wall that doesn’t
have any paintings, decorations, windows or doors.
Lean forward slightly and put your palms flat on the
wall at the height and width of your shoulders. Keep
your feet planted as you slowly bring your body
towards the wall. Gently push yourself back so that
your arms are straight. Do twenty of these.

Exercise 6: Calf Stretches

These strength training exercises for seniors can be
performed sitting or standing.
To do calf stretches while standing, find a wall with
nothing on it. Stand facing the wall with your hands at
eye level. Place your left leg behind your right leg.
Keep your left heel on the floor and bend your right
knee. Hold the stretch for 15 to 30 seconds. Repeat
two to four times per leg.

Exercise 7: Hand and Finger Exercises

The following are exercises to improve flexibility. You
don’t need to stand for these.
In the first exercise, pretend there’s a wall in front of
you. Your fingers will climb the wall until they’re above
your head. While holding your arms above your head,
wiggle your fingers for ten seconds. Then, walk them
back down.

Exercise 8: Shoulder Rolls

This is a simple exercise for seniors. You can do it
seated or standing.
Rotate your shoulders gently up to the ceiling, then
back and down. Next, do the same thing, but roll them
forwards and then down.

34